A Case of Spitzoid Melanoma

Spitzoid melanoma is a subtype of melanoma that, clinically and histologically, resembles a Spitz nevus. Clinically, spitzoid melanomas usually evolve from amelanotic nodular lesions, growing to 1 cm or more in diameter. They often remain clinically undiagnosed because of their wide variety of clinical appearances and a lack of pigmentation. Distinguishing a Spitz nevus from a spitzoid melanoma can be extremely difficult. Features that favor the diagnosis of a spitzoid melanoma are asymmetrical shape, diameter greater than 1 cm, a lesion with a deep invasive component, and a high degree of cytologic atypia. There have been only rare reports in the literature of the presence of giant cells in malignant melanoma, and the presence of these cells may result in its misdiagnosis as a histiocytic tumor. We present a case of spitzoid melanoma on the right ankle of a 22-year-old-woman.     

Analysis of the interaction of human C5a and C5a des Arg with human monocytes and neutrophils: flow cytometric and chemotaxis studies

C5a and C5a des Arg are potent complement-derived mediators that bind receptors on peripheral blood leukocytes and tissue-specific cellular elements to elicit and amplify inflammatory and immunomodulatory reactions. To study the interactions of C5a and C5a des Arg with these cells, fluorescein conjugates of these ligands were prepared by a new technique and their binding to monocytes, neutrophils, platelets, and endothelial cells was studied with flow cytometry. Fluoresceinated C5a produced neutrophil myeloperoxidase release and chemotaxis and also bound rabbit anti-C5a antibody much like native anaphylatoxin; likewise, fluoresceinated C5a des Arg demonstrated retention of biologic and antigenic activities. Both fluorescein-conjugated C5a and C5a des Arg bound to monocytes and neutrophils in a concentration-dependent, saturable, and homogeneous manner, but 10- to 15-fold higher concentrations of C5a des Arg were required to attain saturable binding of these leukocytes. Ligand binding was specifically inhibited by native purified human C5a in a concentration-dependent manner, while it was unaffected by C3a or N-formyl-methionyl-leucyl-phenylalanine-lysine. There was no evidence of a C5a receptor-negative subpopulation of monocytes or neutrophils. Moreover, comparative binding experiments with leukocytes from multiple normal volunteers showed that a greater percentage of monocytes than neutrophils bound C5a at less than saturable concentrations of ligand (P less than 0.05, 0.5 to 5.0 nM). A representative half-maximal binding of fluorescein-conjugated C5a (C5a des Arg) binding to monocytes and neutrophils was 1.2 nM (30 nM) and 2.6 nM (68 nM), respectively. In contrast, fluorescein-conjugated C5a did not specifically bind to human platelets or umbilical vein endothelial cells.     

Chagas disease reactivation: cutaneous manifestations in a transplanted patient

Chagas disease is an endemic zoonosis caused by a protozoan agent called Trypanosoma cruzi. It is mainly transmitted by a hematophagous vector, and less frequently by blood transfusion, transplacental and solid organ transplant. In most cases, primary infection is not diagnosed and the disease progresses to a chronic phase. Immunosuppressed patients are a vulnerable population that may present an acute, atypical and severe reactivation of the chronic form of this disease. We hereby report a case of a female patient, who received a renal transplant with immunosuppressive treatment, who was diagnosed with a chagasic hypodermitis secondary to an acute reactivation of a chronic phase of this disease. We describe the clinical features, epidemiological and histopathological findings, treatment and course.     

Patients with drug-eluting stents and management of their anticoagulant therapy in cutaneous surgery

Whether a patient has a drug-eluting stent (DES) implanted may not seem to be an immediate concern for a dermatologist. However, the clinician needs to consider a patient's risk of bleeding if a patient is to undergo a cutaneous surgical procedure. Patients with skin cancer are generally older with a higher risk of comorbidities such as cardiovascular disease with history of cardiac stent implantation. After DES placement, patients are typically on long-term dual antiplatelet therapy, which increases the risk of bleeding. However, stopping antiplatelet therapy prematurely can lead to serious thrombotic complications. Thus, when performing a dermatologic procedure in a patient with a DES, the physician must weigh the risks of bleeding complications with continuing antiplatelet therapy against the risk of thrombotic complications associated with stopping antiplatelet therapy. The aim of this review is to identify the issues for the dermatologist and the dermatologic surgeon surrounding the perioperative treatment of patients with a DES and to discuss the treatment of patients with an implanted DES.     

Trichothiodystrophy and Associated Anomalies: A Variant of SIBIDS or New Symptom Complex?

Abstract: Trichothiodystrophy is characterized by sparse, short, sulfur-deflclent hair. Numerous symptom complexes have been described in which the hair abnormaiity represents a constant feature. We report a boy with trichothiodystrophy, ichthyotic skin changes, onychodystrophy, chronic neutropenia, osteoscierosis, hypothyroidism, nystagmus, growth and mentai retardation, and microcephaiy, who developed a progressive encephalopathy with ataxia and optic atrophy at 2.5 years of age. in addition to a deficient cystine ievei identified on a hair sampie, a disturbance in the composition of other amino acids was present. Ai-though features were reminiscent of osteoscierosis, ichthyosis, brittie hair due to trichothiodystrophy, impaired inteliigence, decreased fertiiity, and short stature (SIBIDS) and couid represent a variant of this disorder, findings in our patient may refiect a new trichothiodystrophy symptom compiex that carries a poor prognosis for survivai beyond chiidhood.     

Bowen's disease clinically simulating an onychomatricoma

Onychomatricoma (OM) is an uncommon benign tumor clinically characterized by a thickened yellowish nail with transverse over curvature. A pigmented variant has recently been described. Histologically, the diagnosis requires 3 prerequisites: (1) a fibroepithelial tumor consisting of 2 portions: the proximal zone (under the proximal nailfold, characterized by deep epithelial invaginations and a fibrillary and fibrocytic stroma), whereas the distal zone (corresponding to the lunula) presents with multiple digitations along its connective tissue axes; (2) a matricial tumor typified by a thick keratogenous zone; and (3) a thick nail plate, perforated by cavities. We describe a case that appears clinically identical to a pigmented OM, but with histologic malignant patterns. Because histologic features were consistent with Bowen's disease, we ruled out a malignant OM. We report a new variant of Bowen's disease presenting as OM, and this observation underlines the necessity for a histologic assessment of all forms of OM, especially those associated with a pigmented band (a sign sometimes observed in Bowen's disease).     

Two squamous cell carcinomas arising in a linear epidermal naevus in a 28-year-old female

The development of a squamous cell carcinoma (SCC) in a linear epidermal naevus is a rare event previously reported in long-standing and often extensive lesions of middle-aged to elderly patients. To the best of our knowledge, this case appears to be only the second report of an SCC arising in a linear epidermal naevus in a young patient and the first report of two SCCs developing in a small epidermal naevus, over a short time, in a young patient with no other risk factors.     

Conflicts of interest in dermatology

Conflicts of interest exist in dermatology when professional judgement concerning a primary interest, such as research validity, may be influenced by a secondary interest, such as financial gain from a for-profit organization. Conflict of interest is a condition and not a behaviour, although there is clear evidence that gifts influence behaviour. Little has been written about conflicts of interest in dermatology. This series of papers raises awareness of the subject by exploring it in greater depth from the perspective of a dermatology researcher, an industry researcher, a dermatology journal editor, a health services researcher and a patient representative. Collectively, they illustrate the many ways in which conflicts can pervade the world of dermatology publications and patient support group activities.     

Periocular vitiligo with onset around a congenital divided nevus of the eyelid

Leukoderma in association with congenital melanocytic nevi is a rare phenomenon; nevertheless several reports have been published in the literature. We present a 15-year-old boy born with a pigmented lesion on the lower and upper eyelid diagnosed as a congenital divided nevus of the eyelid. At the age of 13, he developed a depigmented area around the nevus and was diagnosed at first as having a halo nevus in a congenital nevus. Over the next two years, an area of depigmentation appeared around the contralateral eye. At the present time, the patient has bilateral periocular depigmentation. Congenital divided nevus of the eyelid is a rare lesion, and no reports have been published to date of depigmentation in association with this lesion. Our patient presented with depigmentation around the nevus as in a halo nevus phenomenon, although at the present time, the depigmented area has a symmetric periocular distribution, and therefore can be labeled as periocular vitiligo associated with a congenital divided nevus.     

Palisaded encapsulated neuroma (PEN): an often misdiagnosed neural tumor

We describe a unique case of a young man with concomitant Fragile X syndrome who presented with a dome-shaped pearly papule under the nose that had enlarged over 9 months. Histology demonstrated a smoothly contoured spindle cell neoplasm of the dermis with neuroid structures and foci of palisaded growth, consistent with a diagnosis of palisaded encapsulated neuroma (PEN). Palisaded encapsulated neuroma is a benign neural neoplasm of the skin or mucosa that displays histologic features of both a neurofibroma and a schwannoma. However, unlike these tumors, PEN lacks the implications for underlying systemic disease or malignancy. Palisaded encapsulated neuroma is a commonly underdiagnosed and misdiagnosed tumor that, once identified clinically and histologically, can be easily excised without recurrence.     

Erythema elevatum diutinum: an "idiopathic" case

Erythema elevatum diutinum (EED) is a rare condition with an unclear pathogenesis. Initially classified within neutrophilic dermatoses, it is now considered as a leukocytoclastic vasculitis accordingly to its histopathologic pattern. Several clinical presentations as well as many associated diseases are reported in the literature. We report a new case of EED in a 58-year-old man who presented with a three-month history of plaques and nodules on the extensor surfaces of hands, elbows, knees, ankles, forearms, and buttocks. Histology showed a leucocytoclastic vasculitis, suggestive of the diagnosis of EED. Screening for an associated pathology, namely a paraproteinemia or a solid cancer, was negative. Treatment with dapsone leads to amelioration within few weeks.     

Severe bullous pemphigoid in an infant--successful treatment with rituximab

Abstract:  Bullous pemphigoid (BP) is a disease typical of the elderly, and rare in children. With appropriate therapy, the clinical course is usually self-limited. We report on a 5-month-old boy with a severe BP, unresponsive to systemic corticosteroids, intravenous immunoglobulins, dapsone, and cyclosporine A. There is growing evidence for rituximab as a treatment option in refractory autoimmune bullous diseases also in children. We saw a marked improvement in skin lesions within a couple of days after the first dose of rituximab, and blisters disappeared. Monitoring of CD19-positive cells showed a fast decrease to almost zero and a slow recovery within 4 weeks. At this time, new blisters appeared and another dose of rituximab was given. After the second dose of rituximab a long-lasting effect without development of new bullae was observed.     

A case of Bowen's disease showing a clinical tendency toward spontaneous regression

We present a case of Bowen's disease showing a clinical tendency toward spontaneous regression. The patient, a healthy 86-year-old woman, complained that erythema had appeared on her left forearm two years earlier and had gradually enlarged. At the first examination, we observed a well-demarcated, 4 x 3 cm, erythematous plaque, partically covered with crusting and erosions near the wrist. Diagnosis of Bowen's disease was confirmed by a biopsy. Since the patient refused surgery and also discontinued hyperthermic treatment with disposable chemical pocket warmers after a brief trial, we decided to continue the observation of disease progression without any treatment. Two years after the initial visit, the lesion showed a clinical tendency toward spontaneous regression, with a fine erythematous plaque that showed the obscurely demarcated border of the lesion. After three years, although the patient exhibited a similar symptomatic improvement, a skin biopsy showed a few residual tumor cells. At the patient's request, we chose to observe the progress of the lesion. We review the literature of cases of Bowen's disease that have shown a similar tendency toward spontaneous regression, which have been rare.     

Cutaneous manifestations as presenting sign of autoimmune lymphoproliferative syndrome in childhood

Autoimmune lymphoproliferative syndrome is a disorder due to a defect of lymphocyte apoptosis, whose clinical manifestations consist of hyperplasia of lymphoid tissues and autoimmune diseases. We report on a 26-month-old child who presented with frequent eruptions of weals and angioedema without any apparent triggering factor, who subsequently developed an erythematopapular rash with a histological pattern of a lymphoplasmacellular infiltrate. Familial anamnesis revealed a history of lymphoadenomegaly and massive spleen and liver enlargement in her sister. Functional and molecular analysis led to a diagnosis of type 1a autoimmune lymphoproliferative syndrome. Immunophenotyping of the cutaneous lesion revealed the presence of an inflammatory infiltrate with a considerably high number of Langerhans cells. Cutaneous features such as urticaria, angioedema and vasculitis in children with a personal and familial history of hyperplasia of lymphoid tissues may be a presenting sign of a systemic disease, such as autoimmune lymphoproliferative syndrome.     

The differing views of male and female patients toward chaperones for genital examinations in a sexual health setting

OBJECTIVES: To determine the attitudes of male and female patients to the use of chaperones during genital examination within a sexually transmitted diseases clinic. STUDY DESIGN: An anonymous, self-completed questionnaire was administered to patients attending the Melbourne Sexual Health Centre, Australia, between September and October 2006. RESULTS: The participation rate among male and female patients was 60% (166 of 276) and 73% (153 of 210), respectively. Among male patients, only 7.3% and 6.0% expressed a desire for a chaperone when being examined by a male and female practitioner, respectively. Among female patients, 26.8% desired a chaperone if they were going to be examined by a male practitioner when compared with 5.5% for a female practitioner (P <0.001). Around one-third of male and female patients indicated they would feel uncomfortable having a chaperone present and this did not vary by the sex of the practitioner (P >0.48). For female patients being examined by a male practitioner, the desire for a chaperone was associated with having had a previous cervical smear (odds ratio, OR = 0.35, 95% CI: 0.12-0.98, P = 0.04) and feeling comfortable about the presence of a chaperone present (OR = 28.9; 95% CI: 11.1-75.0; P <0.001), but not age (P = 0.16) or previous genital examination (OR = 0.55, 95% CI: 0.21-1.45, P = 0.2). CONCLUSIONS: In a sexual health setting, female patients undergoing genital examination by a male clinician should be asked whether they would like a chaperone to be present.     

Dermoscopic and Histological Correlation of an Atypical Case of Pyogenic Granuloma

Pyogenic granuloma (PG) is a common, rapidly growing, benign vascular proliferation of skin and mucous membranes generally showing, on dermoscopy, a typical pattern characterized by a red to dark pink homogeneous area surrounded by a white collarette. A case of PG in a 5‐year‐old girl showing an atypical dermoscopic pattern characterized by the presence of a central, irregular, whitish‐yellow amorphous structure with a peripheral crown of polymorphous, atypical vessels is reported and discussed.     

Woolly Hair Nevus with an Ipsilateral Associated Epidermal Nevus and Additional Findings of a White Sponge Nevus

Abstract:  We report a case of a 16-year-old male with a woolly hair nevus, an associated ipsilateral epidermal nevus who also had a white plaque on his tongue, clinically diagnosed as a white sponge nevus. The concurrent findings of a white sponge nevus, a woolly hair nevus, and an ipsilateral epidermal nevus, to our knowledge, have not been previously reported.     

Identification of causative chemicals of allergic contact dermatitis using a combination of patch testing in patients and chemical analysis

3 cases of allergic contact dermatitis from industrial rubber products were investigated using a combination of patch testing in patients and chemical analysis of causative rubber products by gas chromatography (GC), GC-mass spectrometry (GC-MS) and high-performance liquid chromatography (HPLC). Our studies revealed N-isopropyl-N'-phenyl-p-phenylenediamine (IPPD), a typical rubber allergen, as a causative chemical in a case from a brand of heavy-duty rubber gloves and a case from a black rubber ring for car manufacture, and zinc ethylphenyldithiocarbamate (ZEPC), a dithiocarbamate (DTC)-type accelerator, as a causative chemical in a case from a brand of rubber work gloves: both IPPD and ZEPC, which showed positive patch test reactions, were confirmed in the extracts of the causative rubber products by GC, GC-MS and/or HPLC.     

Trichilemmal carcinoma--a rare tumor: case report

Trichilemmal carcinoma is a rare cutaneous cancer that usually occurs on photoexposed areas in elderly individuals. Most of the time, there is a unique lesion that presents a papulonodular aspect with possible keratosis or ulceration on the top of it. We report on a case of this rare tumor, discussing various aspects of this entity and possible therapy. Simple excision with adequate safety margin is a safe, low-cost and effective mode of treatment for this type of carcinoma. Although a rare form of neoplasia, trichilemmal carcinoma has good prognosis when treated correctly.